Advancing Integrated Diabetes Care Enabling Roll-out of the Ontario Diabetes Strategy (ODS) in Central East LHIN

Transcription

1 Advancing Integrated Diabetes Care Enabling Roll-out of the Ontario Diabetes Strategy (ODS) in Central East LHIN April 2010 Item 3.3 b)

2 Outline People with Diabetes and those at Risk in the CE LHIN CE LHIN Diabetes Initiatives Pre Ontario Diabetes Strategy Central East LHIN Diabetes Network Living with Diabetes Guide CE LHIN Diabetes Indicator Project Ontario Diabetes Strategy Brief Overview Diabetes Education Team Service Expansion Regional Coordinating Centre development Other components

3 People with Diabetes and those at risk of developing Diabetes

4 Current Situation Current prevalence of diabetes well above provincial average in all planning zones of the CE LHIN Complexity of clients at current Diabetes Education Centres (DEC) has increased more Type 2 diabetics now on insulin Type 1 Adult resources limited in Northeast Cluster Introduction of pump program for Type 1 has increased workload, stretching human resources across the LHIN Large proportion of current DEC clients have Mental Health needs this occurs in all communities Central East Diabetes Network has built a foundation for continued LHIN level (regional) coordination joint quality improvement initiatives underway.

5 Rate of Diabetes Mellitus by CE LHIN Planning Zone (2006) Ontario Haliburton Highlands Kawartha Lakes Peterborough City County Northumberland-Havelock Durham East Durham West Durham North/Central Scarborough Agincourt - Rouge Scarborough Cliffs - Scarborough Centre Source: ICES (2006) Planning Zone Percent

6 Central East LHIN: Living with Diabetes Guide 25,000? copies of Living Well with Diabetes Guide printed. Translation to French, Tamil and Cantonese is underway.

7 Central East LHIN: Diabetes Indicators Pilot Project Purpose: Develop and implement a standardized tool and process for measuring and collecting qualitative and quantitative data for relevant outcomes for diabetics The development of this tool and subsequent data collection will permit DECs to: have a better understanding of patient data related to the identified outcomes encourage coordinated best practices in these areas and facilitate information sharing amongst the DECs. These outcomes also investigate client adoption of self-management principles. The project will better prepare DECs in the CE LHIN for the eventual rollout of the provincial Diabetes Registry and the ehealth program. Pilot Sites: Ross Memorial Hospital; Ontario Shores Weight Metabolic Clinic; Scarborough Hospital; Peterborough Regional Health Centre

8 Ontario Diabetes Strategy: Aims Reduce Modifiable Risk Factors: A public awareness campaign highlighting risk factors; Enhancements to the EatRight Ontario Program*; and Focused initiatives targeting high risk populations (Aboriginal, South Asian, Asian, African- Caribbean, Hispanic, and Low-income). Expand Services: Creation of up to 14 Regional Coordination Centres to align/coordinate local diabetes services; Increasing the number of diabetes education teams; and Expanding availability of services such as insulin pumps, bariatric surgery and dialysis Improve Services: Assessment of existing and development of new self-management tools for patients and providers; and Increased adoption of clinical practice guidelines and evidence-based care; Manage Performance: Setting targets (monitored publicly) for the attachment of Ontarians with diabetes to primary care providers and increasing the number of patients receiving three key tests/exams within guideline periods. Primary Care Physicians will be able to monitor their own progress through provider specific Diabetes Care Reports and through the Diabetes Registry

9 ODS Regional Coordinating Centre - Overview The regional coordination centre will provide leadership for all diabetesrelated services within the LHIN. Up to 14 Regional Coordination Centres will be established around the province based on input from LHINs and other key stakeholders The leadership for the regional diabetes program will be established within a provider agency that ideally is a leader in community-based diabetes care. The regional centre will lead the development of a regional diabetes program in each LHIN. The regional centre will support the development and operations of a system of services that achieve excellence in outcomes for people with diabetes

10 ODS Service Expansion In August 2009, the Diabetes Expert Panel endorsed the use of needs-based planning to determine how best to distribute the equivalent of 93 diabetes teams over a three year period Wave 1 As part of Wave 1 Service Expansion, the LHIN recommended three new Community Waves 2-4 Integration and Outreach Diabetes Education Teams Durham Region (Host: Durham Region Diabetes Network) 1 RN, 0.5 RD, 0.5 Social Work Scarborough (Host: West Hill CHC) 1 RN, 0.5 RD, 0.5 Social Work Northeast (Host: Ross Memorial Hospital) 1 RN, 1 RD Waves 2, 3 and 4 ( ) will see an additional 53 (106 FTEs) diabetes teams or equivalent be implemented across the province. The CE LHIN has been allocated: 2 teams (4 FTEs) in Q1 10/11 3 teams (6 FTEs) in Q3 10/ teams (3 FTEs) in Q1 11/12 Not be restricted to existing programs and resources (as it was in phase 1) and will be placed in primary care settings, wherever possible

11 Strengthening the CE LHIN Diabetes System by Service Cluster: Wave 2, 3,4 ODS Service Expansion

12 Northeast and Durham North Central Patient Complexity by Census Tract/ First Nation Location of Diabetes Education & Primary Care* sites *Siting of FHG, FHO, and other Primary Care sites to be provided by MOHLTC 1. Port Hope CHC - DEC 2. City of Kawartha Lakes CHC 3. Brock CHC - DEC 4. Kawartha North FHT 5. Peterborough Networked FHT 6 6. Haliburton Highlands FHT Minden Haliburton Highlands FHT Haliburton 8. Curve Lake First Nations 9. Alderville First Nations 10. Hiawatha First Nations 11. Mississaugas of Scugog First Nations 12. Northumberland Hills Hospital - DEC Peterborough Regional Health 8 Centre DEC (also Type 1 Pediatrics) 14. Ross Memorial Hospital - DEC Campbellford Memorial Hospital - 2/14/20 DEC 5/ Haliburton Highlands Hospital DEC 17. Lakeridge Health Port Perry DEC Port Perry Medical Associates - FHO Markham Stouffville Uxbridge site 17 DEC 20. Kawartha Lakes Family Health Team

13 Scarborough Patient Complexity by Census Tract Location of Diabetes Education & Primary Care* Sites (CHC, FHT) *Siting of FHG, FHO, and other Primary Care sites to be provided by MOHLTC 1. Taibu CHC 6. Rouge Valley Health System - Centenary 2. West Hill CHC main site site DEC (non-ministry funded) 3. West Hill CHC satellite 7. The Scarborough Hospital General site - 4. West Hill CHC - satellite DEC 5. Scarborough Academic FHT 8. The Scarborough Hospital Birchmount site DEC 9. Carefirst FHT (Scarborough/Markham)

14 Durham East and West Patient Complexity by Census Tract Location of Diabetes Education & Primary Care* sites *Siting of FHG, FHO, and other Primary Care sites to be provided by MOHLTC 4 1. West Durham FHT 2. Oshawa CHC - DEC 3. Oshawa Clinic FHG 4. Taunton Health Centre 5. Ontario Shores Centre for Mental Health Sciences (Weight Metabolic Clinic) 6. Oshawa Health Centre FHG Village of Taunton Mills Primary Care Clinic 8. Canadian Mental Health Association Durham NPlead clinic 9. Charles H Best Centre Type 1 only (Child and Adult) 10. Lakeridge Health Bowmanville DEC 11. Rouge Valley Ajax/Pickering DEC 12. Courtice Health Centre 13. Lakeridge Health Oshawa -DEC

15 Service Expansion Waves 2-4 (Mar ): Considerations: Areas of continuing unmet need, current services and Wave 1 teams Areas with high prevalence/incidence/projected growth of diabetes Areas with high priority populations in the LHIN (low-income, Aboriginal, Asian, people with mental health issues, seniors)

16 CE LHIN Recommended Principles for Service Expansion Establish a foundation for improved integration across communities and health care providers Build capacity by cluster in CE LHIN (Scarborough, Durham, Northeast) Assign champion/lead organization to establish specialized teams/network for high needs/risk populations (e.g. Diabetics with Mental Health, Aboriginal, Type 1, Visible Minorities, Chiropody) Promote an outreach/hub-spoke model to improve quality of care, promote consistency/standardization and to support underserved/rural populations and communities (e.g. assessment tools, diabetes indicator collection, education tools, training for health care professions who are not diabetes experts, referrals) Link new teams with Wave 1 Host sites - although host agency can be different, a common focus on community integration and outreach to primary care and special needs populations needs to remain. New and existing teams need to collaborate to promote improved quality of care for patients

17 CE LHIN Recommended Principles for Service Expansion - continued Integrate with Primary Care select primary care locations that will be leaders and fully embrace needs to support clients beyond their rostered populations. Social Work, mental health support and chiropody are important elements of the diabetes education and care team capacity should be built in all three clusters to ensure appropriate access. Clients should be enabled and providers trained to support client/caregiver Self Management of their diabetes.

18 CE LHIN Wave 2 ODS Service Expansion Recommendations Priority Community Priority Population 1 Scarborough: Malvern Community African, Caribbean, South Asian (Tamil, Indian) 2 LHIN-wide Mental Health Population People with diabetes and mental health needs 3 LHIN-wide Aboriginal Durham: Mississauga's of Scugog and South Oshawa Northeast: Curve Lake, Hiawiatha, Love Sick Lake (Ptbo FN) and Alderville 4 Northeast Cluster (including Peteroborough, Northumberland, CKL, Haliburton) 5 North Whitby/Oshawa Type 2 Diabetics; Seniors Type 1 Diabetics - Specialty Team including Chiropody 6 Scarborough: Chinese/Asian Chinese/Asian population living in CE LHIN 7 City of Kawartha Lakes Type 2 Diabetics; Seniors 8 Peterborough and Area Type 2 Diabetics; Seniors 9 Rural Northumberland County Type 2 Diabetics living in rural communities surrounding Port Hope, Cobourg and Campbellford 10 Haliburton-Minden Type 2 Diabetics; Seniors

19 Ontario Diabetes Strategy Wave 1 and 2 Service Expansion Wave 1 Approved Sites: 1. Durham Region (Host: Durham Region Diabetes Network) 2. Scarborough (Host: West Hill CHC) 3. Northeast (Host: Ross Memorial Hospital) Wave 2 Recommendations Communities [Prioritized & Possible Primary Care Host] 10 1 Scarborough Malvern Community; 2-MHLHIN-wide Mental Health Population; 3-AB LHIN-wide Aboriginal Population 4-T1 Northeast Type 1 DM; 3-AB 5 North Whitby/Oshawa; Suggested host(s): T1 8 6 Scarborough Chinese/Asian Population 3-AB 3-AB 3-AB 7 City of Kawartha Lakes; Suggested host(s): AB 9 8 Peterborough and Area; Suggested host: 5 2-MH Rural Northumberland County; Haliburton-Minden T1 2-MH